The nurse admits a female client to the emergency department who arrives with a black eye and reports
of headache, chronic pain, GI problems, menstrual irregularities, and anxiety. A previous physical
workup was negative. The nurse should assess the client for which priority problems? Select all that
apply.
1.Premenstrual syndrome
2.Physical or sexual abuse
3.Irritable bowel syndrome
4.Self-destructive potential
5.Migraine headache
2 & 4.
Physical or sexual abuse, and self-destructive potential
what is the chain of infection?
1. etiologic agent (microorganism)
2. reservoir (source)
3. portal of exit from reservoir
4. method of transportation
5. portal of entry to the susceptible host
6. susceptible host
what Is the most effective way to prevent spread of microorganisms?
Hand hygiene
,What does PPE consist of?
Gloves, gown, mask, eye protection
During a nursing assessment, the client states he is 70 years old and has a history of staphylococcus
infections, increased intraocular pressure, and blurred vision. The nurse concludes that which item
reported by the client is a risk factor for the development of cataracts?
1. History of staphylococcus infections
2. Increased intraocular pressure
3. Stated age of client
4. Long duration of blurred vision
3. age of the client
A 92-year-old client who is very hard of hearing is hospitalized. Which action by the nurse is appropriate
when conducting the admission interview and assessment of the client?
1. Use a cotton swab to clean cerumen in the client's ear before the interview.
2. Speak louder into the client's ear determined to have better hearing.
3. Maintain normal pitch of the voice and face the client during the interview.
4. Put new batteries in the hearing aid to ensure proper functioning.
3. Maintain normal pitch of the voice and face the client during the interview.
A 72-year-old client has been in the ICU for the past 2 days. Which intervention would be the most
appropriate in decreasing the risk for sensory deprivation? Select all that apply.
1. Remove equipment from the room.
2. Explain procedures and routines to the client upon admission.
3. Provide a clock and calendar in the client's room.
4. Maintain a balance of activity and rest periods.
5. Maintain constant conversation when in the client's room.
3. Provide a clock and calendar in the client's room.
4. Maintain a balance of activity and rest periods.
, The nurse must apply an elastic bandage to support a client's sprained ankle. Which action should the
nurse take during this procedure?
1.Moderately stretch the bandage and wrap it from distal extremity to proximal.
2. Wrap the extremity loosely enough to insert two fingers beneath the bandage.
3. Maintain a tight stretch with each wrap of the bandage.
4. Start proximal to the injury site and work distally.
1. Moderately stretch the bandage and wrap it from distal extremity to proximal.
All of the following clients visit the emergency room during one shift. For which clients should the nurse
expect the healthcare provider to prescribe an antibiotic? Select all that apply.
1. Cat bite to the hand of an elderly client
2. Laceration from broken glass in a 6-year-old client
3. Stab wound in the arm of a 37-year-old client
4. Closed fracture to the ankle of a 40-year-old soccer player
5. A wrist sprain in a 17-year-old who was playing basketball
1. Cat bite to the hand of an elderly client
2. Laceration from broken glass in a 6-year-old client
3. Stab wound in the arm of a 37-year-old client
A client on complete bedrest is at risk for disuse syndrome. The nurse should consider which client goal
as appropriate?
The client has shorter periods of immobility.
The client remains free of contractures in lower extremities.
The nurse turns the client every 2 hours.
The nurse performs passive range of motion to lower extremities every 4 hours.
The client remains free of contractures in lower extremities.